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An HIV-infected girl with an abscess at her l

Prepared by...Aurmporn Oberdorfer, MD, PhD
Virat Sirisanthana, MD
Department of Pediatrics, Chiang Mai University, Thailand

eft arm (Page 2/2)

Differential diagnosis
1.
Bacterial abscess

2.

Abscess from BCG as an immune reconstitution syndrome
Investigations
1.
Aspiration at the abscess: pus and blood ~ 0.3 ml (Figure 2).
Gram stain: numerous PMN, no bacterial seen
AFB stain: positive 2+ (Figure 3)
2. Chest X-ray: normal
3.
Tuberculin skin test: 72 hours later.... 17 mm. in diameter as in figure 4.
   
Figure 2: Pus obtained from needle aspiration
Figure 3: AFB positive from pus aspiration
Figure 4: Tuberculin skin test: indurated 17 mm. in diameter
Diagnosis: BCGitis as an immune reconstitution syndrome

Discussion: As a high prevalence of tuberculosis in Thailand, immunization with Bacillus Calmette-Guerin (BCG) at birth (+ booster at the age of 6 years) is in the Thai Expanded Programme on Immunization guidelines. With epidemic of HIV infection, the policy has not been changed, since 1) the vaccine is effective in preventing tuberculosis 2) although, the frequency of BCG-related complications may be slightly higher in HIV-infected infants compared with normal infants, these complications are usually mild (1-2). In the highly active antiretroviral therapy (HAART) era, there is a syndrome called "Immune reconstitution inflammatory syndrome, or Immune restoration disease" (3-4). Reconstitution of cellular immunity to mycobacterial antigens was one of the common components of this syndrome. BCG can act as a mycobacterial antigens as has been previously reported in an infant (5).

Questions: What is the appropriate management in this case?
Answer: The patient should be treated with isoniazid and rifampin for 6-9 months.
Questions: What should be a precaution in the situation when an HIV-infected child already immunized with BCG is about to receive potent antiretroviral therapy?
Answer: We would recommend closed observation of the child during the first 3 months of potent antiretroviral treatment for signs of regional or disseminated BCG infection. If it occurs, the aspirated specimens should be examined for acid fast bacilli organism. If there are AFB organisms, the lesion(s) is(are) typical of regional BCG infection and the other mycobacterial infections could be clinically excluded, the patient should be treated with isoniazid and rifampin for 6-9 months. If other mycobacterial infection can not be excluded the child should receive combination of 3 antimycobacterial drugs, including isoniazid, rifampin and pyrazinamide until the organism is confirmed as BCG, after which pyrazinamide should be ceased. Treatment should last for 6-9 months.
References:
1.
O'Brien KL, Ruff AJ, Louis MA, et al. Bacillus Calmette-Guirin complications in children bom to HIV- 1-infected women with a review of the literature. Pediatrics 1995;95:414-8
2.
Sirisanthana V. Bacille Calmette-Guerin (BCG) vaccine complications in HIV-infected children. J Infect Dis Antimicrob Agents. 1995;12:63-67. Click for pdf file
3.
In Thai: (View,encoding,Thai-Windows) ѵ ѹ. Immune Reconstitution Inflammatory Syndrome 㹼ͪշҵҹ . ⪵ԾԷع, ѧ ԴҳԪ, ѧ Ţ, (óҸԡ). Update on Pediatric Infectious Diseases 2004. dا෾ : ѷ Żþ ӡѴ 2547. p 287-93. click for pdf file
4.
French MA, Price P, Stone SF. Immune restoration disease after antiretroviral therapy. AIDS 2004,18:1615-27.
5.
Sharp MJ, Mallon DF. Regional Bacillus Calmette-Guerin lymphadenitis after initiating antiretoriviral therapy in an infant with human immunodeficiency virus type 1 infection. Pediatr Infect Dis J 1998;17:660-2

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